News From ACFAS

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ACFAS' workshops are hitting the road again with the Simple to Complex Forefoot Revisional Surgery Workshop and Seminar coming to a location near you. Participate in this interactive learning opportunity, which starts on a Friday evening with a presentation on "Common Forefoot Surgical Complications—How to Deal with Them" and continues on Saturday with a hands-on sawbone workshop where you'll get to practice the cutting-edge techniques you've learned.

This workshop is open to surgeons who are currently practicing or still in training and will be available in the following cities in 2013: Jacksonville, FL; Chicago, IL; Dallas, TX; New York, NY; and in 2014: Tysons Corner, VA; and Manhattan Beach, CA. Register to attend the one nearest you! Program attendees will earn up to 12 continuing education contact hours.

To register or for more information, visit acfas.org/comingtoyou. Registration is filling up fast, so register today. Need an easier way to give your patients all the information they need before they have surgery? ACFAS has just the tool to help-- the Perioperative Patient Education CD. This peer-reviewed patient education CD is full of informational handouts explaining the risks and benefits of surgery, details on preparing for surgery, a description of the procedure and post-op instructions for some of the most common types of surgery, including Achilles Tendon Disorders, bunions, chronic ankle instability, flatfoot, fracture repair, hallux rigidus, hammertoe, tailor’s bunion and ankle arthroscopy. Each handout is also customizable for you to conveniently add your own individual patient notes as well as your contact information before printing.

To order the Perioperative Patient Education CD or for a complete listing of topics and other patient educational CD offerings, visit acfas.org/marketing. Are you taking full advantage of all your membership with the College has to offer? One perk of being an ACFAS member is access to group purchasing power through ACFAS’ Benefits Partner, Henry Schein Foot and Ankle. Group purchasing power pricing means lower prices on medical and surgical supplies, pharmaceuticals, and equipment. Henry Schein also combines these savings with a high level of service, same-day shipping and a dedication to the podiatric profession and even a free cost-savings analysis with your current supplies.

To see how Henry Schein is a valuable partner to your practice’s success and to receive your free cost-savings analysis, call (800) 323-5110 or email Ryan Crothers at Henry Schein.

Foot and Ankle Surgery

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To characterize the kinematic changes associated with the use of flexor digitorum longus tendon transfer and medial displacement calcaneal osteotomy to treat stage II posterior tibial tendon dysfunction, a study was held to evaluate plantar-pressure distribution in 73 patients and 51 feet. Plantar pressure distribution and AOFAS score were evaluated at 48 months post-surgery. Pedobarographic parameters included lateral and medial force index of the gait line, peak pressure (PP), maximum force (MF), contact area (CA), contact time (CT) and force-time integral (FTI).

PP, MF, CT, FTI and CA were reduced in the lesser-toe region while MF was increased in the forefoot region. There was statistical significance to these changes. Statistically significant correlations between AOFAS score and loading parameters of the medial midfoot also were observed.


A new study determined that medium-term results for total ankle replacement (TAR) are satisfactory overall, but there is a high redo rate for periprosthetic osteolysis related to the TAR AES implant. The study involved a prospective series of 84 AES TAR implants, 25 of which underwent revision for osteolysis at an average 59.8 months. Eight patients had hydroxyapatite (HA) coated models and the others had titanium-hydroxyapatite (Ti-HA) coatings. Radiographs were systematically analyzed on Besse's protocol and evolution was tracked on AOFAS scores. The 94 specimens obtained for histologic analysis during revision were re-examined, with specific concentration on foreign bodies.

No metallosis or polyethylene wear was detected at revision. AOFAS global and pain scores declined respectively from 89.7/100 at one year postoperatively to 72.9 before revision and from 32.5/40 to 20.6/40, although global scores remained the same in 25 percent of patients. Radiologically, all patients exhibited tibial and talar osteolytic lesions, 45 percent exhibited cortical lysis and in 25 percent the implant had collapsed into the cysts. All specimens demonstrated macrophagic granulomatous inflammatory reactions in contact with a foreign body and the cysts exhibited necrotic remodeling. Some of the foreign bodies could be identified on optical histologic examination with polyethylene in 95 percent of the specimens and metal in 60 percent. Unidentifiable material was associated due to the presence of a brownish pigment in 33.3 percent of the Ti-HA-coated models and flakey bodies in 44.4 percent of the HA-coated models and 18.2 percent of the Ti-HA-coated models.


A study by researchers in Italy has found that nonanatomical ligament reconstruction with a fibular periosteal flap was effective in bringing high-demand athletes who suffered from chronic lateral ankle instability back to the level of functioning they had before their injuries. The study examined 40 patients between the ages of 17 and 30 who had suffered grade III ankle sprains and did not experience success after undergoing a course of supervised conservative management for at least six months. Participants also underwent a lateral compartment reconstruction with a fibular periosteal flap and were evaluated on the basis of several metrics at the study's six month, one, two and three year time points. Researchers did not observe any major complications in the study's participants. They also found that mean American Orthopaedic Foot and Ankle Society (AOFAS) scores and Foot and Ankle Outcome Scores (FAOS) improved from 69.4 and 71.4, respectively, in the preoperative group to 97.2 and 94.4, respectively, at the final follow-up. Range of motion in the injured ankle was equal to that of the other ankle in all but two patients after two years.

Practice Management

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New research published in JAMA Internal Medicine estimates that the U.S. health system racks up $9.8 billion per year dealing with common avoidable infections, which amounts to potentially significant savings for hospitals that absorb the cost. Such infections can be largely avoided through hand washing and other disinfection measures, and better monitoring of harmful infections in surgical settings would help identify potential interventions and offer a more precise estimate of surgical site infection prevalence. The study found that the biggest cost center was central-line associated bloodstream infections at $45,814 per case. Infections involving drug-resistant bacteria added another 27 percent to that cost for a total of $58,614, and patients were likely to be hospitalized an additional 15.7 days versus those who did not suffer a healthcare-associated infection. Estimated costs of ventilator-associated pneumonia, surgical site infections and Clostridium difficile infections were $40,144, $20,785 and $11,285 per case, respectively. Catheter-associated urinary-tract infections were the least costly avoidable infection, totaling $896 per case. Surgical site infections were the most common and represented slightly more than 33 percent of total annual costs.


Physician groups must update the "Notices of Privacy Practices" by Sept. 23, due to recent changes to the Health Insurance Portability and Accountability Act. Failure to do so could result in fines and penalties. The notices must be written in plain language. They must describe how the healthcare organization can use and disclose a patient's protected health information. They must also state the patient's rights regarding his or her health information and how those rights can be exercised. They must identify the healthcare organization's legal duties regarding patients' protected health information. Finally, they must explain how patients can submit complaints about their privacy rights, and where more information can be found.

The notice must be made available to patients no later than the date of the first service delivery, and should be posted clearly and prominently in the organization's office and on its website. Organizations must make an effort to obtain written acknowledgement from the patient that they have received the notice.


Medical practices have a responsibility to track patient collections, especially with more financially strapped patients paying in cash. There are various strategies to follow to prevent an outflow of money from the practice. One tip is to create a simple spreadsheet that can be posted on the desk of the front-office staff collecting the co-pays, which should include the patient name, description of the money in, or money out, the amount that was paid and the date. At the start of each day, the front-office staffer counts the money in the cash box, and any money over a set amount needs to be deposited to the lead physician or the practice administrator. Those monies then must be tracked and deposited in the bank with a deposit slip displaying this same amount.

The front-office person will write down every single payment on the spreadsheet throughout the day, and this also can be a digital document, programmed to record all calculations. Writing down every single payment ensures that each patient who owes has been collected on. If someone in the office borrows money for an employee lunch, office supplies or some other business expense, that should be recorded and calculated in a cash-out area at the end of the day.

At the day's conclusion, all the money in and out should balance. The front-office staff is mandated to manage the cash flow of the practice. The practice administrator or manager has to sign off on a weekly basis, how the week's in and out activity has occurred. Following these simple steps ensures that the practice collects what is required, patients do not receive a bill, money gets deposited into your bank account and there are no questions of where the funds have gone.


Surgeons now have access to a risk calculator that accurately predicts the chance of death or other negative outcomes for more than 1,500 operations. It lists the probabilities of nine or 10 outcomes per operation, the expected length of the hospital stay and whether an individual patient's risk is above or below average. Before, many surgeons lacked the tools to accurately assess risk for most procedures and would reassure patients with generalities. The calculator takes into account an individual patient's risk factors via a 23-question web page that can be filled out with a doctor or by patients themselves if they know the name of the surgery. While not expected to appreciably lower the number of surgeries performed, it will allow doctors to provide realistic expectations. Also, doctors may generate additional reimbursement from the Centers for Medicare & Medicaid Services under the Physician Quality Reporting System by using the calculator. The calculator's formula was generated from outcomes from 1.4 million patient procedures.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has issued a fact sheet on participating in the 2013 Physician Quality Reporting System (PQRS)/Medicare Electronic Health Record (EHR) Incentive Pilot Program. Professionals who qualify under the program can satisfy Stage 1 meaningful use (MU) clinical quality measure (CQM) reporting requirements while also reporting for the PQRS program by submitting their clinical quality data electronically. Participating physicians are required to submit 12 months of CQM data between Jan. 1 and Feb. 28, 2014. The fact sheet covers determining eligibility for the program, indicating intent to participate, confirming that an EHR vendor is PQRS-certified and the EHR is MU-certified, selecting measures to report, producing required reporting files and submitting test data before data submissions for payment, among other issues. The fact sheet is available here.


The American Medical Association (AMA) wants to stop physician practices from receiving less pay than the contracted amounts agreed to in fee schedules due their increasing receipt of consumer credit card payments. A central pain point are the fees associated with the cards, as physicians may pay up to 5 percent per transaction when office staff enters a card number in a credit card reader machine. Such fees are often opaque, leading to physicians receiving less than the negotiated prices for services. The AMA is calling on the Centers for Medicare and Medicaid Services (CMS) to ban insurers from paying physicians less than contracted rates when using electronic payment methods. The association says in a letter that CMS also should encourage payers to adopt new electronic funds transfer (EFT) standards that promote the White House's administrative simplification efforts before a Jan. 1, 2014, deadline.


The number of physicians accepting new Medicare patients rose by one-third between 2007 and 2011 and is now higher than the number of physicians accepting new private insurance patients, according to a Department of Health and Human Services report. In 2007, about 925,000 doctors billed Medicare for their services. In 2011, that number had risen to 1.25 million, according to the report by the HHS Office of the Assistant Secretary for Planning and Evaluation.

Medicine, Drugs and Devices

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A report from the Department of Health and Human Services' Office of the Inspector General (OIG) urges the Centers for Medicare and Medicaid Services (CMS) to provide more education to suppliers and beneficiaries about proper billing practices for diabetes test strips (DTS) in order to address questionable Medicare payments for such products. The report estimated that Medicare permitted $425 million in dubious bills from about 10 percent of DTS suppliers in 2011, and concluded that Medicare's competitive bidding program realized some success in this area. OIG studies came to the conclusion that DTS billing is an area susceptible to fraud, waste and abuse, and in 2011 Medicare paid roughly $1.1 billion to 51,695 suppliers for DTS that were provided to 4.6 million beneficiaries.


Joint pain and swelling is a problem many postmenopausal women struggle with. Some studies have suggested that one cause may be low vitamin D and calcium levels. However, a randomized clinical trial found that vitamin D and calcium supplements are no better at relieving joint problems than a placebo. Researchers looked at 1,911 women, half taking 1,000 milligrams of calcium and 400 units of vitamin D daily, and the other half taking a placebo. Both groups had similar rates of joint pain and joint swelling, about 73 percent and 34 percent respectively. The groups also had similar rates of smoking, physical activity, body mass index and other factors. After two years, 74.6 percent of the group receiving supplements still had joint pain, compared to 75.1 percent in the placebo group. Joint swelling was reported by 34.6 percent who took supplements and 32.4 percent in the placebo group.